Q In a general paediatrics population, is medical advice from on call paediatricians compared with that from advice nurses
associated with (1) fewer parents or guardians seeking unadvised medical care, and (2) fewer parents or guardians obtaining
unadvised significant care for their children?

METHODS

Design:

Allocation:

concealed.

Blinding:

blinded (healthcare providers).

Follow up period:

72 hours.

Setting:

a university general paediatrics faculty practice in Los Angeles, California, USA.

Patients:

1182 parents or guardians who called for after hours telephone advice from the on call paediatrician regarding their children
(mean age 3 y, 55% boys). Exclusion criteria: calls not for medical advice, calls for emergency medical conditions, and calls
in which the callers were unable to consent (eg, non-English speaking or not a legal guardian).

Interventions:

Outcomes:

number of participants who sought unadvised health care (ie, level of care pursued by the caller was higher than that advised
by the on call paediatrician or advice nurse, such as emergency department visits when only office care or self care had been
advised) and number of participants who obtained significant unadvised health care for their children, such as hospital admission,
within 72 hours of the initial telephone call.

CONCLUSION

In a general paediatrics population, medical advice from on call paediatricians or advice nurses did not differ for number
of parents or guardians who sought unadvised medical care or those who obtained unadvised significant medical care for their
children.

Commentary

The tension between cost effective and safe care is played out nightly on the telephone when anxious parents call asking what
to do about a child’s presumed illness. The network of after hour, telephone advice services using protocols to direct decision
making has grown exponentially in North America in the past decade.1 In the UK, National Health Service Direct was launched in 1998, and 40% of calls concern children.2 Previous studies have found appropriate rates of referral to emergency departments and low risk of morbidity and mortality
after telephone advice provided by non-physicians who used clinical algorithms.3 However, the study by Lee et al contributes to our understanding of this phenomenon by examining an important subset of the advice seeking population: those
who are deemed “well enough” to delay care. This study attempted to ascertain the safety of advice given by nurses to delay
care or to provide self care compared with that given by paediatricians. The results suggest that nurses using triage algorithms
are safe substitutes for physicians. In the 2 cases where nursing advice was followed up by significant unadvised care that
included hospital admission, detailed clinical summaries suggest that hospital admission was not indicative of poor advice
from nurses.

It is important to recognise the context of the study. The sample was drawn from a highly educated, privately insured population
accustomed to having a paediatrician available for their after hours calls. Further studies should be done in populations
that are less educated and have fewer resources. Studies with parents who are less knowledgeable and have poorer communication
skills may reveal differences not apparent in this study.